Outcome of children with acetylcholine receptor (AChR) antibody positive juvenile myasthenia gravis following thymectomy

Most evidence supporting the benefit of thymectomy in juvenile myasthenia gravis (JMG) is extrapolated from adult studies, with only little data concerning paediatric populations. Here we evaluate the outcome of children with generalized JMG who underwent thymectomy between 1996 and 2010 at 2 tertiary paediatric neurology referral centres in the United Kingdom. Twenty patients (15 female, 5 male), aged 13months to 15.5years (median 10.4years) at disease onset, were identified. Prior to thymectomy, disease severity was graded as IIb in 3, III in 11, and IV in 6 patients according to the Osserman classification. All demonstrated positive anti-acetylcholine receptor (AChR) antibody titres. All patients received pyridostigmine and 14 received additional steroid therapy. Transternal thymectomy was performed at the age of 2.7-16.6years (median 11.1years). At the last follow-up (10months to 10.9years, median 2.7years, after thymectomy), the majority of children demonstrated substantial improvement, although some had required additional immune-modulatory therapies. About one third achieved complete remission. The postoperative morbidity was low. No benefit was observed in one patient with thymoma. We conclude that thymectomy should be considered as a treatment option early in the course of generalised AChR antibody-positive JMG.

Atypical melanocytic naevi following melanotan injection

Melanotan is a synthetic analogue of alpha melanocyte stimulating hormone (a-MSH) that stimulates melanogenesis. It is sold on the internet and tanning salons as a quick 'tanning jab'. We report a patient who developed multiple new onset atypical naevi within one week of receiving two Melanotan injections. This case highlights the potential risk of Melanotan in stimulating dysplastic naevi or possibly malignant melanoma.

Treatment of bleeding upper aerodigestive tract tumor-a novel approach with antifibrinolytic agent: case series and literature review

OBJECTIVES/HYPOTHESIS

Symptomatic bleeding among patients with advanced upper aerodigestive tract tumor is a challenging problem. Given the limited options for topical treatment, embolization is often required to control the hemorrhage. There are recent reported cases of novel and successful treatment of patients with recalcitrant tracheo-bronchial bleed with tranexamic acid. We therefore described our initial experience of four consecutive cases of patients with bleeding from advanced aerodigestive tract tumor, successfully treated with oral tranexamic acid.

STUDY DESIGN

Case series.

METHODS

Case series of four consecutive patients with acute bleed from upper aerodigestive tract tumors, treated with oral tranexamic acid. Tranexamic acid was administered topically and systemically (1gm PO QID) for the orophayngeal and supraglottic tumor cases, where as systemic-only therapy were administered to the patients with nasal and nasopharyngeal tumors.

RESULTS

None of the patients experienced further bleeding following the commencement of tranexamic acid treatment, and no adverse effect was noted. These are the first reported cases of symptomatic upper aerodigestive hemorrhage being controlled with tranexamic acid. It is increasingly being used in patients with life-threatening bleeding following trauma and major surgery. The optimum dose of tranexamic acid is undetermined. In vivo studies suggested concentrations of 10 μg/mL to 16 μg/mL for optimal anti-fibrinolytic effect, which is achievable with 1gm QID of oral administration. Large randomized controlled trials assessing the utility of tranexamic acid in various orthopedic surgeries did not show increased thromboembolic events.

CONCLUSIONS

Tranexamic acid should be considered for patients with symptomatic nonarterial bleeding of the upper aerodigestive tract tumors.

LEVEL OF EVIDENCE

4.

Neurocardiogenic syncope: a rare presentation of pharyngeal lymphoma

Syncope is a common symptom of patients attending emergency departments, yet presents significant diagnostic and therapeutic challenges. We present a rare cause of recurrent vasovagal syncope with predominant cardioinhibitory response due to lymphoma surrounding and compressing the carotid artery treated successfully with radiotherapy.

Stakeholder perspectives on transitions of nursing home residents to hospital emergency departments and back in two Canadian provinces

Major gaps exist in our understanding of transitions in care for older persons living in nursing homes. The purpose of the study was to identify key elements, from multiple stakeholder perspectives, that influence the success of transitions experienced by nursing home residents when they required transfer to a hospital emergency department. This interpretive descriptive study was conducted in two cities in the Canadian provinces of British Columbia and Alberta. Data were collected from 71 participants via focus groups and individual interviews with nursing home residents, family members, and professional healthcare providers working in nursing homes, emergency departments, and emergency medical services. Transcripts were analyzed using constant comparison. The elements contributing to the success of transitions reflected a patient- and family-centered approach to care. Transitions were influenced by the complex interplay of multiple elements that included: knowing the resident; critical geriatric knowledge and skilled assessment; positive relationships; effective communication; and timeliness. When one or more of the elements was absent or compromised, the success of the transition was also compromised. There was consistency about the importance of all the identified elements across all stakeholder groups whether they are residents, family members, or health professionals in nursing homes, emergency departments or emergency medical services. Aspects of many of these elements are modifiable and suggest viable targets for interventions aimed at improving the success of transitions for this vulnerable population.